Healthcare Provider Details

I. General information

NPI: 1831422112
Provider Name (Legal Business Name): GIBSON OF JAX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 CRICKET COVE RD E
JACKSONVILLE FL
32224-8401
US

IV. Provider business mailing address

3775 CRICKET COVE RD E
JACKSONVILLE FL
32224-8401
US

V. Phone/Fax

Practice location:
  • Phone: 904-254-0337
  • Fax: 904-223-4368
Mailing address:
  • Phone: 904-254-0337
  • Fax: 904-223-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 5525
License Number StateFL

VIII. Authorized Official

Name: MRS. KATHERINE WOODY GIBSON
Title or Position: PRESIDENT
Credential: MA, CCC-SLP
Phone: 904-254-0337